This infant is my son.He was born at 36 weeks of gestation. He is growing well, and seems to be meeting his milestones. So I believe that his neurological development is also normal.

But last week, at 9 weeks of age, we noticed that his leg was vibrating or twitching for numerous seconds. Since then I have been keeping the count of the number of beats that occur in each episode, and at times it is well up to 20 or more. He has about 3 such episodes in a day.

Furthermore, I can induce the vibrating movements at his ankle on flexing his foot upwards. When I do that, the clonus like movements occur for anywhere between 3 to 14 beats, and it is on both sides.

Doc should I be seeking medical advice or is this normal in a young infant?

The Expert, Ren Chats Answers

Ankle clonus

No doubt, ankle clonus is often seen in normal infants below 5 months of age, but it would not generally be sustained. At times it can also be elicited in them, especially if the examiner maintains increased tension of the muscles being examined. But a series of violent confused involuntary movements that persist for more than 10 beats should be dealt with suspicion at any stage of life, also during early infancy.

Even at this early phase of neurobehavioral development, it indicates an abnormally hyperactive stretch reflex, which when normal provides steadiness and coordination to the movements. This hyperactive stretch reflex may or may not get corrected during the normal process of nervous system development. Therefore, the diagnostic decision depends on the presence of other signs, and not only on the persistence of the clonus.

Infant with gastroesophageal reflux and dystonia gets ankle clonus

Most people do not worry about the regurgitation, gastro-oesophageal reflux, in young infants. It is only when the baby develops dystonic movements a neurological consultation is sought. And Sandifer’s syndrome is a combination of gastro-oesophageal reflux and dystonia such as torticollis, extensor spasm and dystonic posture. Disturbed behaviour pattern like irritability, excessive crying, and abnormal head or eye movements is also noted in the affected infants.

Though the precise underlying cause of Sandifer’s syndrome is not yet quite clear, its neurological manifestations certainly arouse concern for the newly noticed ankle clonus in your 9 weeks old infant.

Points to ponder

I do understand your baby is showing good progress after his treatment for gastro-oesophageal reflux, but the following three lacunae in the case report given arouse my concern.

Missing birth history. The ill effects of birth process are the most feared cause of nervous system injury in infants, more so in those who are born preterm. Gastro-oesophageal reflux is common among the neurologically compromised, and clonus is a sign of impairment in carrying down the commands from higher centres to the concerned neuromuscular unit.

Clonus on both sides? If ankle clonus is generally on both the sides, or you can elicit it on both the sides, then I have nothing extra to add. But if you elicit clonus on one side and the other ankle also goes into involuntary rhythmic movements then it is an exaggerated reaction. And it needs good neurological evaluation.

Yes, you should seek medical advice.

Most ankle clonus, even if they are fairly well-sustained, are of No significance if they are Not associated with corroborative neurological findings. In your son’s case, the ankle clonus could be a part of dystonia associated with gastro-oesophageal reflux, or a mark of some underlying neurological concern. Therefore both, his treating doctor and a neurologist need to reassess the case in the light of this new development. Sometimes children with Sandifer’s syndrome suffer for years from abnormal movements for they do not seek advice for gastro-oesophageal reflux, and vice versa the evaluation for neurodevelopmental disorders is also essential.

Single consultation is not sufficient, nor is a short follow-up. Several consultations each with a different expert at a different point of development also do not resolve diagnostic dilemma in dynamically developing kids. To arrive at a definite diagnosis close follow-ups at regular intervals with the chosen medical team are needed till the baby is at least 18 months old.

Please continue the follow-up evaluations till your son is up and about on his feet even if he is supposedly doing well. Hopefully No abnormality will be found, even then it is worth the trouble on the basic principle, “a stitch in time saves nine”

Comments for Infant with GastroesophagealReflux and DystoniaGets Ankle Clonus

Thank you Kristi for providing this additional information. It tells a lot on the rough course your baby had before and during birth.

Therefore, in my opinion, you should keep your son under close follow up with a pediatric neurologist.

I am happy to hear that as yet he is gaining milestones appropriate for his age. There are good chances that he will grow up to he a healthy smart boy, but letting a qualified person evaluate periodically will not hurt.

Please do not get worried. I suggest medical supervision as an essential precaution.With best wishes,Ren Chats

Sep 24, 2015

Reply to my sons caseby: Kristi Wiles

This post was made in regards to my son, and in response to your reply I would like to add a few things.

My son was born at 36 weeks due to preterm labor throughout my pregnancy. I suffered a very large subchorionic hemorrhage and it was present throughout my entire pregnancy. He was born vaginally via forceps due to his heart rate dropping and being turned the wrong direction (sideways). He did not spend time in the nicu except briefly to suction out hisome lungs due to extramarital amniotic fluid inside.